Let me let you in on a secret: winter is coming. Sure as night follows day the NHS will be in the headlines as A&Es and hospital wards fill up and valiant staff struggle to deliver the right care to people in the right place at the right time.
Last winter ministers established a weekly emergency meeting to manage the pressures in the system. The intention may have been a good one but it is no way to run our NHS – it tends to focus on the immediate presenting issues often treating symptoms rather than causes.
And the pressures are not just at wintertime, nor are they just present in acute hospitals. What’s more they tell us something about the current condition of local health and care economies.
The solutions to these bottlenecks, breached four-hour waits and delayed transfers of care are well documented in a library full of guidelines, standards and reports. Some acute trusts and their partners adopt them, some have tried them but not sustained them.
Why has evidence of what works, guidance and reports not led to a wholesale transformation of the way hospitals organise the patient journey?
According to a recent audit of acute care of older people by NHS Benchmarking, 5% of stays in hospital of 21 days or more account for a staggering 41% of total bed days. In that finding alone is a very big pointer to understanding why so many of our hospitals hit gridlock.
That is why NHS Providers, the national organisation of NHS foundation trusts, has established a commission to look at what works and why. This is not just about the experience of older people in acute trusts, the commission will look at other types of delay, in particular delays in discharging from mental health trusts and transfers between other care settings.
It is often said that fixing the problem is not rocket science. I am not so sure. The application of scientific principles, the use of data, adopting lean thinking, designing processes with fewer steps and normalising team working behaviours all feature in those places that have gripped the problem.
The commission is about to start its work. Over the next few months we will seek out those places that have worked out how to change the patient journey and have seen the change through. Our work is focused on understanding the causes and identifying solutions to delayed transfers of care no matter where they occur.
Taking account of patients’ lived experience
Already one thing we have heard is the importance of stories. Taking the perspective of the patient and the journey they go on is an effective way of establishing common purpose and clarity.
Healthwatch has just published a report on its special inquiry into unsafe discharge – Safely home: what happens when people leave hospital and care settings? It underscores its messages and recommendations with the lived experience of patients and family carers.
One of the stories is about Albert who has Parkinson’s. For want of the right support in hospital while waiting for assessment, and timely access to intermediate care he has ended up in a care home.
A lack of pharmacy input meant the importance of administering Parkinson’s drugs at set times was not understood. This had a real impact on his mobility. Delays in arranging suitable intermediate care led to his mobility deteriorating so much that he no longer qualified for help. Albert was finally transferred to a care home where his health and mobility continued to decline.
Jackie told Healthwatch about her father’s experience. His hopes were raised of a transfer to a community hospital, but no one had involved the community hospital team. When they did, the community hospital said it would not take him until a course of intravenous antibiotics had finished.
The family felt let down, not properly involved and uncertain whether they should be seeking a suitable care home or supporting his reablement.
In both cases opportunities to maintain independence and increase the chances of a discharge home were missed. For an older person 10 days in hospital can cost them 10 years of muscle loss. A wait of just two days cancels out the benefits to be had from intermediate care. The longer a medically fit person lingers in hospital the more frail they become and remote the prospects of a return to the life they led before.
Why are insights like these so hard to translate into day-to-day practice? That is why NHS Providers has established the Right Place, Right Time commission to investigate.
NHS Providers will issue a call for evidence to support the commission. We want to hear from NHS trusts of all types, social care, housing providers, families and patients. What changes have you made, how have you gone about making those changes, have they worked and will they last?
By making the process leaner, understanding it end to end, designing change with the frontline, and making sure the patient’s perspective is held at the centre of everyone’s practice we can make sure no hospital is a frailty factory.
Paul Burstow, former minister of state for health, is chair of the Right Place, Right Time commission on care.
